Opioid management program and pain management alternatives

Opioid management program for Commercial plans 

Opioid painkillers provide needed relief to those with acute or chronic pain. But given their potential for harm, and the very real–and pervasive–problem of misuse and abuse, ensuring appropriate use is more critical now than ever before. Our standard opioid management program is aligned with the “CDC Clinical Practice Guideline for Prescribing Opioids for Pain” issued by the Centers of Disease and Prevention (CDC) in November 2022 and contains the following features:

Inappropriate Drug Therapy Combinations
The pharmacy may need to contact the prescriber to resolve these issues:

• Opioids & Medication Assisted Treatment (MAT): reject for an opioid claim secondary to a MAT drug (includes only buprenorphine-combination products)
• Opioids & Benzodiazepine: reject for an opioid drug if the member has an existing claim for a benzodiazepine and vice versa
• Opioids & Prenatal Vitamin: reject for an opioid drug if the member has an existing claim for a prenatal vitamin claim and vice versa

Inappropriate opioid quantities or dosing
The pharmacy may need to contact the prescriber to resolve these issues:

• Members already on opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >90 MME*/day
• Members new to opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >50 MME*/day
• Members new to opioids: reject for Short Acting Opioid prescriptions for >7 day supply
• Members new to opioids: reject for a Long Acting Opioid with no paid claim for a Short Acting Opioid

The following requires prior authorization from the prescriber:

• Members already on opioids: Prior Authorization required for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >180 MME*/day

Therapeutic Dose Limit
The pharmacy may need to contact the prescriber to resolve this issue:

• Cumulative acetaminophen dose check (with opioid-containing drugs) >4 grams/day (reject)

Refill Threshold

• This edit narrows the refill window for Schedule II-V controlled drugs to a 90% threshold at retail pharmacy and 80% at mail order.

Opioid Management Edits
The following require prior authorization from the prescriber if exceeding the limit:

• Members new to opioids: Short Acting Opioids maximum 50 MME*/day
• Members new to opioids: Short Acting Opioids 7 days supply limit
• Members already on opioids: Short Acting Opioids maximum 90 MME*/day. 
• All members: use of Short Acting Opioids required before Long Acting Opioids
• All members: Quantity Limits on all Long Acting Opioids based on FDA maximum dosing frequency (i.e. once daily)
• All members: Maximum 2 opioid fills within a 60-day time period

Pediatric (<19 years of age) Edits 
The following require prior authorization from the prescriber if exceeding the limit:

• All pediatric members: PA required for all opioid containing cough and cold medications
• Pediatric members new to opioids: 3 days supply limit

When patients fill a prescription for an opioid (a covered drug that is a narcotic substance contained in U.S. Drug Enforcement Administration Schedule II), they may choose to obtain a fill in a lesser quantity than the full amount prescribed.  If they do, they may then choose to later obtain the remainder of the prescribed fill.  They will not be responsible for any copayment amount beyond the amount that would normally apply if they obtained the entire fill at once.

Opioid management program for Medicaid/MassHealth ACO plans 

Effective April 1, 2023, Fallon Health ACO plans will begin to follow the MassHealth Unified Formulary. All Massachusetts Medicaid managed care organizations (MCOs) will follow MassHealth’s pharmacy drug coverage and criteria. ACOs are however allowed to have different dose thresholds for opioid dosages.

Please refer to the table below for Fallon Health ACO initiatives, thresholds and dose limits.

Opioid management program for Medicare plans 

There are several opioid safety edits and programs for the Medicare Part D plan year. These impact the following plans: Fallon Medicare Plus, NaviCare, Summit ElderCare PACE, and Fallon Health Weinberg PACE.

Point of Sale (POS) opioid safety edits
CMS requires certain prospective safety edits. These edits will occur when the member is filling the prescription at the pharmacy. These edits require resolution. The pharmacist at the pharmacy may override some of the edits with appropriate codes, may need to consult with the provider, and may need to inform the provider that a prior authorization is required. Since these are safety edits, they will still apply during a member’s transition period; meaning, the claims will still reject with the edits and require resolution. Buprenorphine for medication-assisted treatment (MAT) is not included in the safety edits.

Hospice/palliative care, cancer-related pain, sickle cell disease, and LTC members are excluded from the safety edits. Members have Coverage Determination and Appeal rights under this program.

The edits include:

• Soft edit for concurrent opioid and benzodiazepine use – pharmacy can override
• Soft edit for duplicative long-acting (LA) opioid therapy – pharmacy can override
• Soft edit for concurrent opioid and prenatal vitamins use – pharmacy can override
• Soft edit for concurrent opioid and Medication Assisted Therapy (MAT) use – pharmacy can override
• Care coordination edit at 90 morphine milligram equivalents (MME) and 2 prescribers – pharmacy can override only after consultation with the prescriber, documentation of the discussion, and if the prescriber confirms intent (the opioids and/or day supply is intended and medically necessary for the member), using an override code that indicates the prescriber has been consulted.
• Hard edit for a 7-day supply limit for initial opioid fills (opioid naïve) with a 120-day look- back. If the pharmacy cannot resolve at point of sale (POS), this will require a prior authorization to be submitted. Provider needs to attest that the opioids and/or day supply is intended and medically necessary for the member. Member is considered opioid naïve if there are no opioid claims in the past 120 days.

Medication Therapy Management (Not applicable to PACE)
We are also including special eligibility criteria into our Medication Therapy Management Program (MTMP). In addition to traditional MTMP eligibility, members are eligible for MTMP if they have been identified as an At-Risk Beneficiary (ARB) under a Drug Management Program (DMP)

Comprehensive Addiction and Recovery Act of 2016 (CARA) - Drug Management Program (DMP)
This is a comprehensive opioid management program required under the Comprehensive Addiction and Recovery Act of 2016 (CARA). This is a retrospective DUR program to identify members at risk for frequently abused drugs and conduct case management. Frequently abused drugs are defined by CMS as opioids and benzodiazepines. Buprenorphine for medication-assisted treatment (MAT) is not included in the 90 MME accumulations. The program excludes members with cancer pain, palliative/hospice care, sickle cell disease, and in LTC. Dual/Low Income Subsidy (LIS) members are limited in ability to change plans to avoid intervention once identified as at-risk.
Criteria for identification into the program include any of the below:

• Members with opioid pharmacy claims equal to or greater than 90 MME and 3+ opioid prescribers and 3+ opioid dispensing pharmacies
• Members with opioid pharmacy claims equal to or greater than 90 MME and 5+ opioid prescribers
• Members with any MME level and 7+ opioid prescribers or 7+ opioid dispensing pharmacies
• Members identified as having a history of opioid-related overdose are also included in the DMP.
• Program includes case management and clinical outreach to providers to determine if the member is at risk for opioid overutilization, notifications to the member, potential lock-in restrictions to specific provider(s), pharmacy(ies), and/or at the drug level. Members have appeal rights under this program

Pain management alternatives to opioid products

If you are interested in pain management alternatives to opioid products for your patients, there are many non-opioid medications and treatments available. These include, but are not limited to, those listed below.

Non-opiate medication treatment options (Please note that some medications require PA or may have other utilization management restrictions):

• NSAIDs
• Topical Analgesic
• Cox-II Inhibitors
• Skeletal Muscle Relaxants
• Anti-Depressants
• Anti-Convulsants
• Corticosteroids

Please refer to our formulary for further information about our prescription drug formulary and prior authorization requirements.

Non-medication treatment modalities:

• Chiropractic care
• Physical therapy services
• Behavioral health providers with pain management-related specialties, such as cognitive behavioral therapy, pain management and treatment of chronic pain.

These services may require prior authorization or may be subject to benefit limitations or may not be covered for all plans.

Additional medications and treatments are available which may also serve as pain management alternatives to opioid products. These include other medications, certain other types of therapies, treatment by certain types of non-behavioral health specialists, certain types of surgery, and certain types of injections.

*Morphine Milligram Equivalents are a way to compare different opioid medications based on their strength as compared to morphine